Microwave ablation of large HCC lesions: Added value of CEUS examinations for ablation success control

Sequential thermal ablation in combination with sclerotherapy using lauromacrogol as a successful translative therapy for an unresectable huge biliary cystadenocarcinoma: The first experience assisted by contrast-enhanced ultrasound

Biliary cystadenocarcinoma (BCAC) is an extremely rare intrahepatic cystic tumor. Patients usually present with nonspecific symptoms such as abdominal pain, abdominal distention, and abdominal mass. This tumor occurs most commonly in the left hemiliver and is thought to mainly develop from a benign biliary cystadenoma (BCA). At present, the disease is mainly diagnosed by ultrasound, CT, MR, and other imaging methods, and the main treatment is radical surgical resection. We reported a 75-year-old female with an unresectable huge BCAC (i.e., 161×145×122 mm in three orthogonal directions) and poor general condition (40 in Karnofsky Performance Status, KPS) who received sequential thermal ablation (i.e., cryoablation and microwave ablation) in combination with sclerotherapy using lauromacrogol. The diagnosis of intrahepatic BCAC was confirmed pathologically. Preablation grayscale US showed the BCAC with a clear boundary, regular shape, and cystic-solid mixed echogenicity, which appeared as a huge multilocular cystic lesions with thick internal sepatations. Preablation contrast-enhanced ultrasound (CEUS) showed honeycomb-like hyper-enhancement of the thick internal sepatations and cystic wall in the arterial and portal phase, and sustained enhancement of the thick internal sepatations and cystic wall in the late phase. 6-month postablation CEUS showed non-enhancement in most parts of the lesion in the arterial phase and 6-month postablation MRI showed the volume reduction ratio (VRR) was about 70% . The abdominal pain and abdominal distension were relieved remarkably, and her quality of life was greatly improved (70 in KPS). In conclusion, sequential thermal ablation in combination with sclerotherapy provides a successful translative therapy for this unresectable huge BCAC with a poor general condition, which makes subsequent curative surgery or ablation possible.

Comparison of superb microvascular imaging (SMI) quantified with ImageJ to quantified contrast-enhanced ultrasound (qCEUS) in liver metastases-a pilot study

BACKGROUND

The aim of the study was to compare methods for the assessment of vascularisation of liver metastases (LM) between superb microvascular imaging (SMI), contrast-enhanced ultrasound, and microvascular density (MVD).

METHODS

SMI results were quantified as the vascularisation quotient (VQ), based on a grey-scale analysis with ImageJ image software. Those results were compared to contrast-enhanced ultrasonography (CEUS) values, calculated with VueBox^®. MVD was measured with an anti-CD34 antibody.

RESULTS

This study included 13 patients with LM. The VQ showed a strong correlation with the quantified parameters of contrast-enhanced ultrasound. The parameters of quantified contrast-enhanced ultrasound compared with quantified SMI showed the following statistical correlations: peak enhancement (PE), in arbitrary unit (a.u.) (r=0.72104, P=0.0054), PE in Decibel (dB) (r=0.65918, P=0.00141), Wash-in- Area Under the Curve (WiAUC) in a.u. (r=0.63604, P=0.00194), Wash-in Perfusion-Index (WiPI) in a.u. (r=0.73337, P=0.0043), Wash-in Perfusion-Index (WiPI) in dB (r=0.65642, P=0.0194), Wash-in-Rate (WiR) in a.u. (r=0.7304, P=0.0036) and Wash-in-Rate (WiR) in dB (r=0.82897, P=0.0005).

CONCLUSIONS

Comparison of the two methods, SMI and contrast-enhanced ultrasound (CEUS), for quantitative assessment of vascularisation of LM showed good correlation. The contrast-independent Doppler technique SMI can qualitatively assess the vascularisation of LM.

Feasibility and efficiency of contrast enhanced ultrasound real time guided fine needle aspiration for sentinel lymph node of breast cancer

AIM

To assess the feasibility and efficiency of contrast-enhanced ultrasound (CEUS) real-time guided fine needle aspiration (FNA) for sentinel lymph node (SLN) of breast cancer.

MATERIALS AND METHODS

This retrospective study reviewed 21 breast cancer patients who scheduled for surgical resection performed CEUS real-time guided SLN-FNA and intraoperative SLN biopsy (SLNB). The success rate of CEUS real-time guided SLN-FNA was analyzed. The FNA diagnostic efficiency of SLN metastasis was analyzed compared to SLNB.

RESULTS

Twenty-six SLNs were detected by intradermal CEUS whereas 130 SLNs were detected by SLNB. The median SLNs detected by intradermal CEUS (n = 1) and by SLNB (n = 5) was significantly difference (p < 0.001). All 26 CE-SLNs of 21 patients were successfully performed intradermal CEUS dual image real-time guided SLN-FNA including 5 SLNs of 4 patients which were difficult to distinguish in conventional ultrasound. Compared to SLNB, FNA found 2 of 5 cases of SLN metastasis, the diagnosis sensitivity, specificity, positive predictive value, negative predictive value, false negative rate, false positive rate and Yoden index were 40%, 100%, 100%, 84.2%, 60%, 0%and 40%, respectively.

CONCLUSION

SLN-FNA real-time guided by dual CEUS image mode was technically feasible. Patients with a positive SLN-FNA should be advised to ALND without intraoperative SLNB according to Chinese surgeon and patients' conservatism attitude. But a negative SLN-FNA did not obviate the need of conventional SLNB because of the high false negative rate.

Meta-analysis and systematic review of contrast-enhanced ultrasound in evaluating the treatment response after locoregional therapy of hepatocellular carcinoma

PURPOSE

Contrast-enhanced ultrasound (CEUS) is a useful tool to assess treatment response after percutaneous ablation or transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC). Here, we performed a systematic review and meta-analysis to evaluate the usefulness of CEUS in identifying residual tumor after locoregional therapy.

METHODS

PubMed, Scopus, and Cochrane library databases were searched from their inception until March 8, 2021, for diagnostic test accuracy studies comparing CEUS to a reference standard for identifying residual tumors after locoregional therapy of HCC. The pooled sensitivity, specificity, accuracy, and diagnostic odds ratio (DOR) were obtained using a bivariate random effects model. Subgroup analyses were performed by stratifying the studies based on study design, type of locoregional therapy, CEUS criteria for residual tumor, timing of CEUS follow up, and type of standard reference.

RESULTS

Two reviewers independently evaluated 1479 publications. After full-text review, 142 studies were found to be relevant, and 43 publications (50 cohorts) were finally included. The overall sensitivity of CEUS in detection of residual disease estimated from the bivariate random effects model was 0.85 (95% CI 0.80-0.89). Similarly, the overall specificity was 0.94 (95% CI 0.91-0.96). The diagnostic accuracy was 93.5%. The DOR was 70.1 (95% CI 62.2-148), and the AUROC was 0.95. Importantly, subgroup analysis showed no apparent differences in the diagnostic performance between locoregional therapy (TACE vs. ablation) and criteria used to define residual enhancement, timing of performing CEUS, study design, or type of reference standard.

CONCLUSION

CEUS is a highly accurate method to identify HCC residual tumor after TACE or percutaneous ablation.

Contrast-enhanced ultrasound (CEUS) in HCC diagnosis and assessment of tumor response to locoregional therapies

Hepatocellular carcinoma (HCC) is a global problem constituting the second leading cause of cancer deaths worldwide, thereby necessitating an accurate and cost-effective solution for managing care. Ultrasound is well poised to address this need due to its low cost, portability, safety, and excellent temporal resolution. The role of ultrasound for HCC screening has been well established and supported by multiple international guidelines. Similarly, contrast-enhanced ultrasound (CEUS) can be used for the characterization of focal liver lesions in high-risk populations, and standardized criteria for CEUS have been established by the American College of Radiology Liver Imaging Reporting & Data System (LI-RADS). Following HCC identification, CEUS can also be highly beneficial in treatment planning, delivery, and monitoring HCC response to locoregional therapies. Specific advantages of CEUS include providing real-time treatment guidance and improved diagnostic performance for the detection of residual tumor viability or recurrence, thereby identifying patients in need of retreatment substantially earlier than contrast-enhanced CT and MRI. This review provides a primer on ultrasound and CEUS for the screening and characterization of HCC, with an emphasis on assessing tumor response to locoregional therapies.

The diagnostic performance of contrast-enhanced ultrasound (CEUS) for evaluating hepatocellular carcinoma (HCC) juxtaposed to MRI findings; a retrospective single-center analysis of 292 patients

BACKGROUND

HCC is the most frequent primary liver cancer entity. Major risk factors comprise chronic HBC and HCV infections, ALD or NAFLD. Apart from the anamnesis, the clinical examination and serologic analysis, an essential part of the diagnostic HCC work-up is due to imaging findings from sonography, CT or MRI scans. HCC lesions feature a distinct vascularization pattern: hyperenhancement during early arterial and hypoenhancement/wash-out during portal venous or delayed phases. CEUS facilitates dynamic assessment of microperfusion patterns of suspicious liver lesions.

PURPOSE

The purpose of the present retrospective single-center study was to determine the diagnostic value of CEUS for assessing HCC by comparison with findings from MRI scans.

MATERIALS AND METHODS

Between 2004-2018 292 patients with suspicious liver lesions underwent CEUS and MRI. All patients underwent native B-mode, Color Doppler and CEUS after given informed consent. The applied contrast agent was a second-generation blood pool agent (SonoVue®, Bracco, Milan, Italy). Every CEUS examination was performed and interpreted by a single experienced radiologist (EFSUMB Level 3).

RESULTS

CEUS was performed on all included patients without occurrence of any adverse effects. CEUS showed a sensitivity of 96%, a specificity of 91%, a PPV of 95% and a NPV of 94% for analyzing HCC in comparison with MRI as the diagnostic gold standard.

CONCLUSION

With a distinguished safety profile CEUS shows a high diagnostic accuracy in assessing HCC compared to corresponding results from MRI scans.

[Contrast-enhanced ultrasound (CEUS) and image fusion for procedures of liver interventions]

CLINICAL/METHODICAL ISSUE

Contrast-enhanced ultrasound (CEUS) is becoming increasingly important for the detection and characterization of malignant liver lesions and allows percutaneous treatment when surgery is not possible. Contrast-enhanced ultrasound image fusion with computed tomography (CT) and magnetic resonance imaging (MRI) opens up further options for the targeted investigation of a modified tumor treatment.

METHODICAL INNOVATIONS

Ultrasound image fusion offers the potential for real-time imaging and can be combined with other cross-sectional imaging techniques as well as CEUS.

PERFORMANCE

With the implementation of ultrasound contrast agents and image fusion, ultrasound has been improved in the detection and characterization of liver lesions in comparison to other cross-sectional imaging techniques. In addition, this method can also be used for intervention procedures. The success rate of fusion-guided biopsies or CEUS-guided tumor ablation lies between 80 and 100% in the literature.

ACHIEVEMENTS

Ultrasound-guided image fusion using CT or MRI data, in combination with CEUS, can facilitate diagnosis and therapy follow-up after liver interventions.

PRACTICAL RECOMMENDATIONS

In addition to the primary applications of image fusion in the diagnosis and treatment of liver lesions, further useful indications can be integrated into daily work. These include, for example, intraoperative and vascular applications as well applications in other organ systems.

Evaluation of short-term efficacy of radiofrequency ablation for hepatocellular carcinoma by dynamic three-dimensional contrast-enhanced ultrasound

BACKGROUND

Radiofrequency ablation (RFA) plays an important role in non-surgical treatment of hepatocellular carcinoma (HCC). Accurate assessment of the residual status of HCC after operation is of great significance to the future treatment plan. The efficacy of RFA is often evaluated by various imaging methods in clinic. Ultrasound has attracted more and more attention in clinical evaluation of the efficacy of RFA, because of its non-invasive, convenient, and repeatable advantages. Dynamic three-dimensional contrast-enhanced ultrasound (3DCEUS) can dynamically display the blood perfusion status of tumor tissue in three-dimensional space, which is expected to provide a new imaging method for evaluating the efficacy of RFA.

AIM

To evaluate the short-term efficacy of RFA for HCC by 3DCEUS and the clinical value of 3DCEUS.

METHODS

We retrospectively analyzed 93 patients (including 117 tumors) with HCC who underwent ultrasound-guided RFA at our hospital from March 2016 to November 2018. All patients underwent 3DCEUS one month after operation. Enhanced magnetic resonance imaging (CEMRI) was used as the "golden standard" to analyze the efficacy of 3DCEUS in evaluating the efficacy of RFA.

RESULTS

CEMRI evaluation showed that 82.05% (96/117) of the tumors were completely ablated and 17.95% (21/117) were incompletely ablated. 3DCEUS evaluation showed that 82.91% (97/117) of the tumors were completely ablated and 17.09% (20/117) were incompletely ablated. The sensitivity, specificity, and accuracy of 3DCEUS in evaluating tumor residues after RFA were 90.48% (19/21), 98.96% (95/96), and 97.44% (114/117), respectively. There was no significant difference in diagnostic accuracy between 3DCEUS and CEMRI (P > 0.05).

CONCLUSION

3DCEUS can accurately evaluate the short-term efficacy of RFA for HCC and has high clinical value.

Comparison of CEUS and enhanced CT in evaluating efficacy of TACE for hepatocellular carcinoma

AIM

To evaluate the value of contrast-enhanced ultrasound (CEUS) and enhanced computed tomography (CT) in evaluating the efficacy of transcatheter artery chemoembolization (TACE) for hepatocellular carcinoma (HCC).

METHODS

A total of 96 patients with HCC who underwent TACE at Zhejiang Tumor Hospital were selected as research subjects (a total of 128 lesions). Digital subtraction angiography (DSA), CEUS, and enhanced CT were performed one month after operation, and the results of DSA were used as the "gold standard" to compare the clinical value of CEUS and enhanced CT in evaluating the efficacy of TACE.

RESULTS

The sensitivity (95.18%) and accuracy (95.31%) of CEUS in the diagnosis of residual lesions were higher than those (84.34% and 88.28%, respectively) of enhanced CT (P < 0.05). The specificities of CEUS and enhanced CT in the diagnosis of residual lesions were both 95.56%, and there was no significant difference between them (P > 0.05).

CONCLUSION

CEUS can accurately evaluate the residual lesions of HCC after TACE and has appreciated clinical value, thus providing a reliable imaging method for evaluating the efficacy of TACE.

Evaluation of integrated color-coded perfusion analysis for contrast-enhanced ultrasound (CEUS) after percutaneous interventions for malignant liver lesions: First results

BACKGROUND

 With the rising number of percutaneous ablation therapies in malignant liver lesions there is a need of reliable diagnostics after the intervention to differentiate between reactive changes and tumor.

PURPOSE

To assess the success of percutaneous ablation therapies for malignant liver lesions using CEUS with perfusion analysis.

MATERIAL AND METHODS

Retrospective analysis of perfusion analysis for 67 patients with 94 malignant liver lesions, treated with ablation therapies. The lesions were 70 hepatocellular carcinomas (HCC), 18 metastases, 4 cholangiocellular carcinomas (CCC), 2 lesions remained unclear. CEUS was performed after bolus injection of 1.6-2.4 ml of sulfur-hexafluoride microbubbles. The perfusion analysis was calculated using Peak, TTP, mTT and AUC with integrated software during the late arterial to early portal-venous phase for approximately 9 sec (5-15 sec). For the evaluation of the success after percutaneous treatment the perfusion results were compared to the follow-up control after 6 months with CT and MRI and CEUS.

RESULTS

Perfusion analyses after percutaneous treatment of malignant liver lesions showed highly significant perfusion differences when comparing the center to the surrounding tissue and the margins (p<0.0001) for Peak and also for AUC. 62 lesions were successfully treated, meaning there was no local recurrence after 6 months. In cases of residual tumor CEUS showed a nodular marginal enhancement, the corresponding perfusion analyses showed nodular red and yellow pseudo-color shades.

CONCLUSIONS

Using CEUS and perfusion analysis, a critical analysis of post-ablation defects in malignant liver lesions is possible. With the help of pseudo-colors, remaining tumor-vascularization can be detected.

Use of Ultrasound Contrast Agents in Relation to Percutaneous Interventional Procedures: A Systematic Review and Pictorial Essay

The aim of this article is to provide an inventory of the use of contrast-enhanced ultrasound (CEUS) in relation to percutaneous interventional procedures. The article is structured into a systematic literature review followed by a clinical part relating to percutaneous CEUS-guided procedures. A literature search identified 3109 records. After abstract screening, 55 articles were analyzed and supplemented with pictorial material to explain the techniques. In conclusion, the best-evidenced indications for CEUS-guided interventions are biopsy and ablation of inconspicuous or B-mode-invisible tumors, intraprocedural ablation control and follow-up, as well as percutaneous transhepatic cholangiography and drainage procedures.

Percutaneous Liver Tumour Ablation: Image Guidance, Endpoint Assessment, and Quality Control

Liver tumour ablation nowadays represents a routine treatment option for patients with primary and secondary liver tumours. Radiofrequency ablation and microwave ablation are the most widely adopted methods, although novel techniques, such as irreversible electroporation, are quickly working their way up. The percutaneous approach is rapidly gaining popularity because of its minimally invasive character, low complication rate, good efficacy rate, and repeatability. However, matched to partial hepatectomy and open ablations, the issue of ablation site recurrences remains unresolved and necessitates further improvement. For percutaneous liver tumour ablation, several real-time imaging modalities are available to improve tumour visibility, detect surrounding critical structures, guide applicators, monitor treatment effect, and, if necessary, adapt or repeat energy delivery. Known predictors for success are tumour size, location, lesion conspicuity, tumour-free margin, and operator experience. The implementation of reliable endpoints to assess treatment efficacy allows for completion-procedures, either within the same session or within a couple of weeks after the procedure. Although the effect on overall survival may be trivial, (local) progression-free survival will indisputably improve with the implementation of reliable endpoints. This article reviews the available needle navigation techniques, evaluates potential treatment endpoints, and proposes an algorithm for quality control after the procedure.